Upload
marcello-ribas
View
737
Download
6
Embed Size (px)
Citation preview
Neck DissectionNeck Dissection
Jeffrey Buyten, MDJeffrey Buyten, MD
Susan McCammon, MDSusan McCammon, MD
Francis B. Quinn, MDFrancis B. Quinn, MD
University of Texas Medical BranchUniversity of Texas Medical Branch
Department of OtolaryngologyDepartment of OtolaryngologyGrand Rounds PresentationGrand Rounds Presentation
September 2006September 2006
OutlineOutline
HistoryHistory AnatomyAnatomy
– Nodal levelsNodal levels– Common nodal drainage patternsCommon nodal drainage patterns
StagingStaging ClassificationClassification Sentinel Lymph NodeSentinel Lymph Node
HistoryHistory
Metastatic cervical lymph nodesMetastatic cervical lymph nodes– Early 19Early 19thth Century Century incurable disease incurable disease– 2020thth Century Century improved treatment of improved treatment of
neck diseaseneck disease– 2121stst Century Century second worst prognostic second worst prognostic
indicator for head and neck SCCAindicator for head and neck SCCA
1919thth Century Century 1880 1880 Kocher advocates wide margin Kocher advocates wide margin
lymphadenectomylymphadenectomy
1881 1881 Kocher and Packard recommend Kocher and Packard recommend dissection of submandibular dissection of submandibular
triangle triangle for lingual cancerfor lingual cancer
1885 1885 Butlin questions RND for oral N Butlin questions RND for oral N00 diseasedisease
1888 1888 Jawdynski describes en bloc Jawdynski describes en bloc resection with resection of resection with resection of
carotid, carotid, IJV, SCM.IJV, SCM.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
2020thth Century Century 1901 1901 Solis-Cohen advocate Solis-Cohen advocate
lymphadenectomy for Nlymphadenectomy for N00 laryngeal laryngeal CACA
1905 -1906 1905 -1906 Crile describes en Crile describes en bloc resection in JAMAbloc resection in JAMA
1926 1926 Bartlett and Callander Bartlett and Callander advocate preservation of XI, IJV, advocate preservation of XI, IJV, SCM, platysma, stylohyoid, digastricSCM, platysma, stylohyoid, digastric
1933 1933 Blair and Brown advocate Blair and Brown advocate removal of removal of XI.XI.
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
2020thth Century Century 1951 1951 Martin advocates Radical Neck Dissection after anaysis of Martin advocates Radical Neck Dissection after anaysis of
1450 cases1450 cases– Advocated RND for all cases.Advocated RND for all cases.– Standardized the Radical Neck DissectionStandardized the Radical Neck Dissection
1952 – Suarez describes a functional neck dissection1952 – Suarez describes a functional neck dissection– Preservation of SCM, omohyoid, submandibular gland, IJV, XI.Preservation of SCM, omohyoid, submandibular gland, IJV, XI.– Enables protection of carotid.Enables protection of carotid.
19601960’’s – MD Anderson advocate selective ND of highest risk nodal s – MD Anderson advocate selective ND of highest risk nodal basinsbasins
1967 - Bocca and Pignataro describe the 1967 - Bocca and Pignataro describe the ““functional neck functional neck dissectiondissection””
1975 – Bocca establishes oncologic safety of the FND compared to 1975 – Bocca establishes oncologic safety of the FND compared to the RNDthe RND
Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.
AnatomyAnatomy
Lymph Node LevelsLymph Node Levels– Sloan Kettering nomenclatureSloan Kettering nomenclature– SubgroupsSubgroups
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns
Level ILevel I
Submental triangle Submental triangle (Ia)(Ia)– Anterior digastricAnterior digastric– HyoidHyoid– MylohyoidMylohyoid
Submandibular Submandibular triangle (Ib)triangle (Ib)– Anterior and Anterior and
posterior digastricposterior digastric– Mandible.Mandible.
Marginal Mandibular NerveMarginal Mandibular Nerve Most commonly injury Most commonly injury
dissection level Ibdissection level Ib Landmarks:Landmarks:
– 1cm anterior and inferior 1cm anterior and inferior to angle of mandibleto angle of mandible
– Mandibular notchMandibular notch SubplatysmalSubplatysmal Deep to fascia of the Deep to fascia of the
submandibular glandsubmandibular gland Superficial to facial veinSuperficial to facial vein
Marginal Mandibular NerveMarginal Mandibular Nerve
Hypoglossal nerveHypoglossal nerve Lies deep to the IJV, Lies deep to the IJV,
ICA, CN IX, X, and XIICA, CN IX, X, and XI Curves 90 degrees Curves 90 degrees
and passes between and passes between the IJV and ICAthe IJV and ICA
Ranine veinsRanine veins Lateral to hyoglossusLateral to hyoglossus Deep to mylohyoidDeep to mylohyoid
Level ILevel I IaIa
– ChinChin– Lower lipLower lip– Anterior floor of mouthAnterior floor of mouth– Mandibular incisorsMandibular incisors– Tip of tongueTip of tongue
IbIb– Oral CavityOral Cavity– Floor of mouthFloor of mouth– Oral tongueOral tongue– Nasal cavity (anterior)Nasal cavity (anterior)– FaceFace
Level IILevel II Upper Jugular NodesUpper Jugular Nodes
Anterior Anterior Lateral border Lateral border of sternohyoid, posterior of sternohyoid, posterior digastric and stylohyoiddigastric and stylohyoid
Posterior Posterior Posterior Posterior border of SCMborder of SCM
Skull baseSkull base Hyoid bone (clinical Hyoid bone (clinical
landmark)landmark) Carotid bifurcation Carotid bifurcation
(surgical landmark)(surgical landmark)
Level IIa anterior to XILevel IIa anterior to XI Level IIb posterior to XILevel IIb posterior to XI
– Submuscular recessSubmuscular recess– Oropharynx > oral cavity Oropharynx > oral cavity
and laryngeal metsand laryngeal mets
Spinal Accessory NerveSpinal Accessory Nerve
CN XI – Relationship with the IJVCN XI – Relationship with the IJV
Level IILevel II
Oral CavityOral Cavity Nasal CavityNasal Cavity NasopharynxNasopharynx OropharynxOropharynx LarynxLarynx HypopharynxHypopharynx ParotidParotid
Level IIILevel III
Middle jugular nodesMiddle jugular nodes– Anterior Anterior Lateral border of Lateral border of
sternohyoidsternohyoid– Posterior Posterior Posterior border Posterior border
of SCM of SCM – Inferior border of level IIInferior border of level II– Cricoid cartilage lower Cricoid cartilage lower
border (clinical landmark) border (clinical landmark) – Omohyoid muscle (surgical Omohyoid muscle (surgical
landmark)landmark) Junction with IJVJunction with IJV
Level IIILevel III
Oral cavityOral cavity NasopharynxNasopharynx OropharynxOropharynx HypopharynxHypopharynx LarynxLarynx
Level IVLevel IV
Lower jugular nodes Lower jugular nodes – Anterior Anterior Lateral border Lateral border
of sternohyoidof sternohyoid– Posterior Posterior Posterior Posterior
border of SCMborder of SCM– Cricoid cartilage lower Cricoid cartilage lower
border (clinical landmark)border (clinical landmark)– Omohyoid muscle Omohyoid muscle
(surgical landmark)(surgical landmark) Junction with IJVJunction with IJV
– ClavicleClavicle
Phrenic NervePhrenic Nerve
Sole nerve supply Sole nerve supply to the diaphragmto the diaphragm
C3-5 C3-5 Anterior surface of Anterior surface of
anterior scaleneanterior scalene Under prevertebral Under prevertebral
fasciafascia Posterolateral to Posterolateral to
carotid sheathcarotid sheath
Thoracic ductThoracic duct Conveys lymph from the Conveys lymph from the
entire body back to the blood entire body back to the blood – Exceptions:Exceptions:
Right side of head and neck, Right side of head and neck, RUE, right lung right heart RUE, right lung right heart and portion of the liverand portion of the liver
– Begins at the cisterna chyliBegins at the cisterna chyli– Enters posterior mediastinum Enters posterior mediastinum
between the azygous vein between the azygous vein and thoracic aortaand thoracic aorta
– Courses to the left into the Courses to the left into the neck anterior to the vertebral neck anterior to the vertebral artery and veinartery and vein
– Enters the junction of the left Enters the junction of the left subclavian and the IJVsubclavian and the IJV
Thoracic DuctThoracic Duct
Level IVLevel IV
HypopharynxHypopharynx LarynxLarynx ThyroidThyroid Cervical esophagusCervical esophagus
Level VLevel V
Posterior triangle of neck Posterior triangle of neck – Posterior border of SCMPosterior border of SCM– ClavicleClavicle– Anterior border of Anterior border of
trapeziustrapezius– VaVa Spinal accessory Spinal accessory
nodesnodes– Vb Vb Transverse cervical Transverse cervical
artery nodesartery nodes Radiologic landmarkRadiologic landmark
– Inferior border of CricoidInferior border of Cricoid
– Supraclavicular nodesSupraclavicular nodes
Spinal Accessory NerveSpinal Accessory Nerve
Penetrates deep surface of Penetrates deep surface of the SCMthe SCM
Exits posterior surface of Exits posterior surface of SCM deep to ErbSCM deep to Erb’’s points point
Traverses the posterior Traverses the posterior triangle on the levator triangle on the levator scapulaescapulae
Enters the trapezius about Enters the trapezius about 5 cm above the clavicle5 cm above the clavicle
Level VLevel V
NasopharynxNasopharynx OropharynxOropharynx Posterior neck and scalpPosterior neck and scalp
Level VILevel VI
Anterior compartmentAnterior compartment– HyoidHyoid– Suprasternal notchSuprasternal notch– Medial border of carotid Medial border of carotid
sheathsheath– Perithyroidal lymph nodesPerithyroidal lymph nodes– Paratracheal lymph nodesParatracheal lymph nodes– Precricoid (Delphian) Precricoid (Delphian)
lymph node lymph node
Level VILevel VI
ThyroidThyroid Larynx (glottic and subglottic)Larynx (glottic and subglottic) Pyriform sinus apexPyriform sinus apex Cervical esophagusCervical esophagus
Level VLevel V
NasopharynxNasopharynx OropharynxOropharynx Posterior neck and scalpPosterior neck and scalp
SubgroupsSubgroups IaIa SubmentalSubmental IbIb SubmandibularSubmandibular
IIaIIa Upper jugular (Anterior to XI)Upper jugular (Anterior to XI) IIb IIb Upper jugular (Posterior to XI)Upper jugular (Posterior to XI)
IIIIII Middle jugularMiddle jugular
IVaIVa Lower jugular (Clavicular)Lower jugular (Clavicular) IVbIVb Lower jugular (Sternal)Lower jugular (Sternal)
VaVa Posterior triangle (XI)Posterior triangle (XI) VbVb Posterior triangle (Transverse Posterior triangle (Transverse
cervical)cervical)
VIVI Central compartmentCentral compartment
Face and Scalp Anterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External Ear Anterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouth Anterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb
Lateral Ib, IIa > IIb, III
Teeth except incisors Ib, IIa > IIb, III
Nasal Cavity Anterior Ib
Posterior Retropharyngeal, II, V
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns
Nasal Cavity Posterior Retropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx Supraglottic IIa > IIb, III, IV
Subglottic VI, IV
Cervical esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV
Common Nodal Drainage PatternsCommon Nodal Drainage Patterns
StagingStaging Nx: Regional lymph nodes cannot be Nx: Regional lymph nodes cannot be
assessed.assessed.
N0: No regional lymph node metastases.N0: No regional lymph node metastases.
N1: Single ipsilateral lymph node, N1: Single ipsilateral lymph node, << 3 cm 3 cm
StagingStaging
N2a: Single ipsilateral lymph node 3 to N2a: Single ipsilateral lymph node 3 to 6 cm6 cm
N2b: Multiple ipsilateral lymph nodes N2b: Multiple ipsilateral lymph nodes << 6 cm 6 cm
N2c: Bilateral or contralateral nodes N2c: Bilateral or contralateral nodes << 6cm6cm
N3: Metastases > 6 cmN3: Metastases > 6 cm
StagingStaging
Nasopharyngeal CarcinomaNasopharyngeal Carcinoma– N1 – Unilateral < 6cmN1 – Unilateral < 6cm– N2 – Bilateral < 6 cmN2 – Bilateral < 6 cm– N3a > 6 cmN3a > 6 cm– N3b – Extension to N3b – Extension to
supraclavicular fossasupraclavicular fossa
ThyroidThyroid– N1 – Regional node metsN1 – Regional node mets
N1a - IpsilateralN1a - Ipsilateral N1b - Bilateral, midline, N1b - Bilateral, midline,
contralateral cervical or contralateral cervical or mediastinal LNmediastinal LN
ClassificationClassification
RadicalRadical– Gold standard operationGold standard operation
Modified radicalModified radical– Preservation of non lymphatic structuresPreservation of non lymphatic structures
SelectiveSelective– Preservation of lymph node groupsPreservation of lymph node groups
ExtendedExtended– Removal of additional lymph node Removal of additional lymph node
groups or non lymphatic structuresgroups or non lymphatic structures
Radical Neck DissectionRadical Neck Dissection
Removes Removes – Nodal groups I-VNodal groups I-V– SCM, IJV, XISCM, IJV, XI– Submandibular gland, Submandibular gland,
tail of parotidtail of parotid PreservesPreserves
– Posterior auricularPosterior auricular– SuboccipitalSuboccipital– RetropharyngealRetropharyngeal– PeriparotidPeriparotid– PerifacialPerifacial– Paratracheal nodesParatracheal nodes
RemovesRemoves– Nodal groups I-VNodal groups I-V
PreservesPreserves– SCM, IJV, XI (any SCM, IJV, XI (any
combination)combination)
Notate according to Notate according to which structures are which structures are preservedpreserved
Modified Radical Neck DissectionModified Radical Neck Dissection
Selective Neck DissectionSelective Neck Dissection
Remove high risk lymph node groups Remove high risk lymph node groups based on tumor site.based on tumor site.
SupraomohyoidSupraomohyoid– Levels I-IIILevels I-III
LateralLateral– Levels II-IVLevels II-IV
Selective Neck DissectionSelective Neck Dissection
PosterolateralPosterolateral– Levels II-VLevels II-V– Postauricular nodesPostauricular nodes– Suboccipital nodesSuboccipital nodes
Selective Neck DissectionSelective Neck Dissection
AnteriorAnterior– Level VILevel VI– RLN injuryRLN injury– HyperparathyroidismHyperparathyroidism
Extended Neck DissectionExtended Neck Dissection
Removal of any structures that are Removal of any structures that are routinely preserved in a neck routinely preserved in a neck dissection.dissection.
Notated by naming the structure(s) Notated by naming the structure(s) removed.removed.
Sentinel Lymph NodeSentinel Lymph Node
OverviewOverview NN0 0 NeckNeck TechniquesTechniques ResultsResults
Sentinel Lymph Node HistorySentinel Lymph Node History
1955 First echelon node 1960 “Sentinel node” 1977 Demonstrated in penile
cancer 1992 Morton reintroduced concept
in N0 melanoma Currently widely used in melanoma
and breast cancer therapy.
Sentinel lymph node conceptSentinel lymph node concept
Tumor spreads via lymphatics to a Tumor spreads via lymphatics to a primary node.primary node.
Examination of primary echelon Examination of primary echelon nodes for tumor direct the need for nodes for tumor direct the need for surgical management of the nodal surgical management of the nodal basins.basins.
Sentinel lymph node conceptSentinel lymph node concept Difficulties of lymphatic mapping in head Difficulties of lymphatic mapping in head
and neck (Oand neck (O’’Brien).Brien).
1.1. It is difficult to visualize lymphatic channels It is difficult to visualize lymphatic channels using lymphoscintigraphy because of using lymphoscintigraphy because of proximity to the injection site.proximity to the injection site.
2.2. The radiotracer travels fast in the lymphatic The radiotracer travels fast in the lymphatic vessels.vessels.
3.3. If more than one node is visible, it can be If more than one node is visible, it can be difficult to distinguish first echelon nodes from difficult to distinguish first echelon nodes from second-echelon nodes.second-echelon nodes.
4.4. The SLN may be small and not easily The SLN may be small and not easily accessible (eg, in the parotid gland).accessible (eg, in the parotid gland).
NN0 0 NeckNeck
Occult neck diseaseOccult neck disease– Head and neck cancer Head and neck cancer 30% 30%– Oral cavity CA Oral cavity CA 20% to 45% 20% to 45%
Factors that indicate > 20% chance Factors that indicate > 20% chance of subclinical metastasesof subclinical metastases– Tumor thickness > 4mmTumor thickness > 4mm– Size > 2 cmSize > 2 cm– Anatomic locationAnatomic location
Sensitivity Sensitivity % (range)% (range)
Specificity Specificity % (range)% (range)
PalpationPalpation 35 (30-40)35 (30-40) 35 (27-42)35 (27-42)
CTCT 45 (17-86)45 (17-86) 11 (3-21)11 (3-21)
USUS 46 (42-50)46 (42-50) 21 (11-33)21 (11-33)
MRIMRI 42 (20-70)42 (20-70) 14 (5-26)14 (5-26)
US FNACUS FNAC 42 (27-50)42 (27-50) 00
Accuracy of diagnostic methods in detecting occult Accuracy of diagnostic methods in detecting occult cervical metastases.cervical metastases.
A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomographysentinel node biopsy and positron emission tomography
NN0 0 Neck TreatmentNeck Treatment
T1/T2 N0 oral SCCAT1/T2 N0 oral SCCA– Better 10-year survival in pts who had Better 10-year survival in pts who had
elective neck dissection.elective neck dissection.
T1/T2 N0 tongue SCCAT1/T2 N0 tongue SCCA– 5-year actuarial benefit for elective neck 5-year actuarial benefit for elective neck
managementmanagement
Sentinel Lymph Node Biopsy and Sentinel Lymph Node Biopsy and NN0 0 Oral Cavity SCCAOral Cavity SCCA
Multiple small case series display the Multiple small case series display the feasibility of SLNB in oral SCCAfeasibility of SLNB in oral SCCA
Majority of lesions T1/T2Majority of lesions T1/T2
No standardized techniquesNo standardized techniques
All series compare All series compare – Pre op lymphoscintigraphyPre op lymphoscintigraphy– Intra-op localizationIntra-op localization– Post op pathologyPost op pathology
Pre op TechniquePre op Technique TechnetiumTechnetium
– Day before surgeryDay before surgery– Submucosal injectionsSubmucosal injections– 10-30 MBq Tc 99m per 10-30 MBq Tc 99m per
quadrantquadrant– +/- local anesthesia+/- local anesthesia– Avoid spillageAvoid spillage– Rinse mouthRinse mouth
Dosage does not correlate Dosage does not correlate with ability to identify with ability to identify nodesnodes
Pre op TechniquePre op Technique LymphoscintigraphyLymphoscintigraphy
– DynamicDynamic 45 -60 minutes45 -60 minutes Necessary to clearly identify Necessary to clearly identify
sentinel nodessentinel nodes SLNs seen within 15 minutesSLNs seen within 15 minutes
– StaticStatic Confirms dynamic imagesConfirms dynamic images AP / Lateral / ObliqueAP / Lateral / Oblique Delayed images for non Delayed images for non
revealing dynamic studiesrevealing dynamic studies– Cobalt pencilCobalt pencil
Labels anatomical points Labels anatomical points – Left / right mandibleLeft / right mandible– ChinChin– Cricoid cartilageCricoid cartilage– Sternal notchSternal notch
Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology
Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology
Pre op TechniquePre op Technique
Blue DyeBlue Dye– Submucosal injection Submucosal injection – 2.5% Patent Blue dye 2.5% Patent Blue dye – No more than 20 min No more than 20 min
pre incisionpre incision
Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology
Operative TechniqueOperative Technique
Limited incision guided by Limited incision guided by lymphoscintigraphy and gamma lymphoscintigraphy and gamma probeprobe
Frozen section analysisFrozen section analysis
Operative TechniqueOperative Technique
Gamma probeGamma probe– Examine operative Examine operative
bed for increased bed for increased signalsignal
– Tumor extirpationTumor extirpation– Lead shieldLead shield– Removal of high Removal of high
signal nodessignal nodes– Examine removed Examine removed
node and compare node and compare to operative bedto operative bed
ComplicationsComplications
Reported complication rates < 1%Reported complication rates < 1%– Cutaneous malignancy casesCutaneous malignancy cases
Injury of VII, XI due to limited Injury of VII, XI due to limited exposureexposure
ResultsResults
Sentinel nodes found in > 90% of Sentinel nodes found in > 90% of cases.cases.– Experience mattersExperience matters– Surgeons with less than 10 cases Surgeons with less than 10 cases 56% 56%
success in SLNBsuccess in SLNB Lymphoscintigraphy revealed Lymphoscintigraphy revealed
unexpected bilateral or contralateral unexpected bilateral or contralateral disease in about 14% of ptsdisease in about 14% of pts
About 2-3 SLN per patientAbout 2-3 SLN per patient
ResultsResults
Up to 46% of SLN harbor metastasesUp to 46% of SLN harbor metastases– Fine section frozen analysisFine section frozen analysis
Increases sensitivity to about 95%Increases sensitivity to about 95%
– Immunohistochemical stainingImmunohistochemical staining False negative ratesFalse negative rates
– 10%10%– Grossly involved nodes less likely to take up Grossly involved nodes less likely to take up
tracertracer Better sensitivity for T1/T2 lesionsBetter sensitivity for T1/T2 lesions
– Most false negative results associated with Most false negative results associated with larger T3 lesionslarger T3 lesions
BibliographyBibliography1.1. Lymphatic Mapping and Sentinel Lymphadenectomy for 106 Lymphatic Mapping and Sentinel Lymphadenectomy for 106
Head and Neck Lesions: Contrasts Between Oral Cavity and Head and Neck Lesions: Contrasts Between Oral Cavity and Cutaneous Malignancy Laryngoscope, 116(Suppl. 109):1–15, Cutaneous Malignancy Laryngoscope, 116(Suppl. 109):1–15, 20062006
2.2. Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology Selective Neck Dissection Histopathology
3.3. The value of frozen section analysis of the sentinel lymph node The value of frozen section analysis of the sentinel lymph node in clinically N0 squamous cell carcinoma of the oralin clinically N0 squamous cell carcinoma of the oralcavity and oropharynx LAURENT TSCHOPP, MD, MICHEL cavity and oropharynx LAURENT TSCHOPP, MD, MICHEL NUYENS, MD, EDOUARD STAUFFER, MD, THOMAS KRAUSE, MD, NUYENS, MD, EDOUARD STAUFFER, MD, THOMAS KRAUSE, MD, and PETER ZBÄREN, MD, Bern, Switzerland Otolaryngol Head and PETER ZBÄREN, MD, Bern, Switzerland Otolaryngol Head Neck Surg 2005;132:99-102.Neck Surg 2005;132:99-102.
4.4. A new approach to pre-treatment assessment of the N0 neck in A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography N.C. Hydea,*, E. Prvulovichb, and positron emission tomography N.C. Hydea,*, E. Prvulovichb, L. Newmanc, W.A. Waddingtonb, D. Visvikisb, P. Ellb Oral L. Newmanc, W.A. Waddingtonb, D. Visvikisb, P. Ellb Oral Oncology 39 (2003) 350–360Oncology 39 (2003) 350–360
5.5. The Accuracy of Head and Neck Carcinoma Sentinel Lymph The Accuracy of Head and Neck Carcinoma Sentinel Lymph Node Biopsy in the Clinically N0 Neck Taimur Shoaib1 CANCER Node Biopsy in the Clinically N0 Neck Taimur Shoaib1 CANCER June 1, 2001 / Volume 91 / Number 11June 1, 2001 / Volume 91 / Number 11